Cis 509 : Case Study

The change to value based purchasing has bought many challenges to the healthcare industry. With the change to value-based purchasing for payments, it has changed how healthcare organization receive payment and delivery care. The advantage of have value based purchasing is that it improves the quality of care while reducing cost in an effort of aligning patient’s with the right provider and treatment plan (Minemyer, Jun 29, 2016). However, there are many disadvantages, such as it increases the patient volume as counteracting the reduction of procedure volume (Brown, B. & Crapo, 2016). Also it makes providers more responsible for care that is beyond the expected treatment of care needed (Minemyer, Jun 29, 2016). With quality measures tied

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

A powerful force for change can be created by embracing transparency. According to the Department of Health and Human Services, “transparency is a broad-scale initiative enabling consumers to compare quality and the price of health care services so they can make their own informative choices among doctors and hospitals. This initiative is laying the foundation for pooling and analyzing information about procedures, hospitals and physicians services. In order to create value driven health care, there are four steps to turn raw data into

Healthcare stakeholders know how to value what they have captured and they have come up with many ideas to help with their goal. “Big data could transform the healthcare sector, but the industry must undergo fundamental changes before stakeholders can capture its full value” (Kayyali, B., Knott, D., Van Kuiken, S., 2013). Since the affordable care act has been in place there has been an increase number of patients seeking preventative care or even seeking help for chronic illnesses that they weren’t seen for because of lack of insurance. Because of that, there has been a shortage of physicians, nurses and other healthcare providers. So the stakeholders have another challenge on their hands in trying to hire more doctors and nurses to help with the increase of patients.

One of the biggest impacts on the healthcare industry is the transition from a fee-for-service model to a value-based payment model. This transition is emphasizing the importance of utilizing data captured electronically in EHRs, HIEs, and other clinical and business systems to improve patient care. Payers are implementing payment incentives and penalties based on performance in defined quality and safety metrics through programs such as Blue Cross’ Pay for Performance (P4P) or CMS’ Value-Based Purchasing (VBP). These programs, along with other factors, are resulting in a growing that utilizes data analytics and business intelligence to provide healthcare leaders and physicians with insight into their quality and safety metric status.

In the past several years, there have been several changes in economic policy at federal and state levels. The two economic policies that present to be the most precedent for healthcare leaders with concern to facility reimbursement are the Affordable Care Act (ACA) and the switch from volume to value reimbursement. First, there is the ACA policy, which have affected healthcare facilities and their reimbursement methods. In fact, ever since this policy was implemented, provider reimbursement has started to decrease in terms of fee-for-service payments (The Common-Wealth Fund, 2015). In other words, the intention of this policy was to provide budget relief to the government payers as well as giving providers an incentive to provider patients with great quality of care.

In the hope of better coordinating the care of patients, improving quality and lowering costs, the ACA provides incentives for physicians and hospitals to work together in several ways, such as Accountable Care Organizations (ACO’s) or establishing bundled payments for episodes of care (Martin Gaynor, 2012 ) which has spurred consolidation (Becker, Gamble, & Rosin, 2015). Additionally, compliance with various federal programs such as Meaningful Use requires a significant investment in technology which can be fiscally challenging for smaller provider groups; driving acquisitions of these smaller entities by larger health systems. Other reasons cited by hospital administrators in the pursuit of consolidation is to ensure a steady stream of physician referrals (NPR, 2010), and to create economies of scale and increased efficiencies, the fruits of which result in reduced costs and therefore cheaper care for patients (ProMarket Writers, 2016). However, what most hospital

The Affordable Care Act (ACA) legislated in 2010, has changed the United States health care industry. In addition to universal healthcare, one of the principles of the ACA is the ideal of accountable care. Specifically, adopting an Accountable Care organization (ACO) for Medicare beneficiaries under the fee for service program. An ACO seeks to hold providers and health organizations accountable for not only the quality of health care they provide to a population, but also keeping the cost of care down (1). This is accomplished by offering financial incentives to the healthcare providers that cooperate in, circumventing avoidable tests and procedures. The ACO model, seeks to remove present obstacles to refining the value of care, including a payment system that rewards the volume and intensity of provided services instead of quality and cost performance and commonly held assumptions that more medical care is equivalent to higher quality care (2) .A successful ACO model, will have developed quality clinical work and continual improvement while effectively managing costs, however this is contingent upon its ability to encourage hospitals, physicians, post-acute care facilities, and other providers involved to form connections that aid in coordination of care delivery throughout different settings and groups, and evaluate data on costs and outcomes(3). This establishes the ACO will need to have organizational aptitude to institute an administrative body to manage patient care,

Where there is transparency, there is good accountability thereby reducing government deficit. “Its past time to require transparency of cost and outcomes, so consumers can make informed choices about their care. As patient – consumers increasingly transition to high-deductible plans and other models that increase their cost exposure, they will demand more transparency and information for the choices they need to make. However, simply having some awareness that not every hospital is performing equally well and consumers should be making informed choices is an important first step towards a true market-based healthcare system”(Rita Numerof

The high cost associated with Medicare requires approaching health care reform from an intentional perspective. One approach to help achieve integrated and efficient care is to foster accountability for quality and cost through performance measurements and “shared savings” payment reform. The approach provides a practical and feasible method for providers and organizations to improve their current revenue cycle processes, while maintaining provider incomes and reducing overall health care costs.

Besides, the financial incentives for hospitals and physicians that belong to ACOs, Jaffery & Golden 2013, asked and then answered the question “why would providers join this program? One reason is to prepare for the future”. Fee-for-service reimbursement, which has been how hospitals get paid for their services rely solely on the volume of patient seen without taking into consideration the quality of care provided. Payers today, such as government, commercial insurers, employers, and individual consumers are now requesting on value -based-payment, which consist of delivering the highest level of care at a lower cost. The volume based system even though the traditional way of how payments are made is not a viable long-term option (Jaffery and Golden, 2013, p.98).

Transparency in Healthcare is one of the many debatable changes in the recent healthcare reform. Consenting for pricing, outcomes reports, and standardized performance metrics to be easily accessible to all patients is causing a debate among physicians and insurance not let alone the public. Transparency will bring light into healthcare cost and pricing while enlightening the availability of information needed by consumers to make informed healthcare choices based on their selected physicians. The aspired goal is to implement transparency in healthcare to be recognized, as an important role in which the rendering physician’s contracts will be value based and not quantity driven. The consumer or also know as the patient will have fundamental information on the insurance plan product purchased by him or her, allowing them to understand their patient responsibility towards the rendered cost with

In conclusion, the Pareto analysis will allow us to identify the major energy consumption issues or the major energy conservation savings factors and allow us to prioritize them in a hierarchical manner. Then the decision making process can begin to work to reduce the overall costs and save energy at the same time.

Adding electronic health record (EHR) systems, dashboards and electronic data warehouses to a healthcare practice enables administrators and managing physicians to modernize their service delivery model and work toward high-quality continuity of care. While EHRs provide a cost-effective mechanism for documenting patient encounters and improving patient experiences, some organization leaders don't understand how to leverage analytics to strengthen their practice.

The positive outcomes that have resulted due to value base programs have caused the model to gain traction and ignite one of the largest changes in history in the health care marketplace. By linking reimbursements to service quality, insurers such as the Centers for Medicare and Medicaid Services have facilitated a massive leap forward in the performance of United States health care providers. This achievement is a considerable accomplishment in the face of an institution that has received reimbursement from insurers via a fee-for-service model during the last 75 years. Soon, valued based payment models will represent the norm as more insurers support initiatives such as shared savings program, integrated clinical care, and accountable care payment models.